Textbook of Medical-Surgical Nursing 3e

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Unit 1 Contemporary concepts in nursing

interpreted to mean that the patient requires less nursing care, when actually these patients may have significant medical and nursing needs, all of which demand attention. Ethically, all patients deserve and should receive appropriate nursing inter- ventions, regardless of their resuscitation status. Life support In contrast to the previous situations are those in which a DNR decision has not been made by or for a dying patient. The nurse may be put in the uncomfortable position of initiating life-support measures when, because of the patient’s physical condition, they appear futile. This situation frequently occurs when the patient is not competent to make the decision and the family (or surrogate decision maker) refuses to consider a DNR order as an option. The nurse may be told to perform a ‘slow code’ (i.e. not to rush to resuscitate the patient) or may be given a verbal order not to resuscitate the patient; both are unacceptable medical orders. The best recourse for nurses in these situations is to be aware of hospital policy related to advance directives and reversal of treatment. The nurse should communicate with the doctor. Discussing the matter with the doctor may lead to further communication with the family and to a reconsideration of their decision, especially if they are afraid to let a loved one die with no further efforts to resuscitate. Food and fluid In addition to requesting that no heroic measures be taken to prolong life, a dying patient may request that no more food or fluid be administered. Many individuals think that food and hydration are basic human needs, not ‘invasive measures,’ and therefore should always be maintained. However, some consider food and hydration as means of prolonging suffering. In evaluating this issue, nurses must take into consideration the potential harm as well as the benefit to the patient of either administering or withdrawing sustenance. Research has not supported the belief that withholding fluids results in a painful death due to thirst (Hunter, 2012). Evaluation of harm requires a careful review of the reasons the person has requested the withdrawal of food and hydra- tion. Although the principle of autonomy is supported by the NMBA (2008; Chart 2-3), there may be situations when the request for withdrawal of food and hydration cannot be upheld. For patients with decreased decision-making capacity, the issues are more complex. Preventive ethics and advance directives In order to prevent a dilemma, strategies to help nurses antici­ pate or avoid certain kinds of ethical dilemmas should be part of care planning. A patient may be able to make their wishes known but the legal situation is unclear. When uncer- tainty exists, this may be resolved through a legal petition. In Australia the possibility of a person refusing food and fluid varies between States. Most Australian States and Territories have legislation regarding end-of-life decisions. It is important to be aware of the legislation relevant to the State in which the nurse is practising. Frequently, dilemmas occur when the healthcare practi- tioners are unsure of the patient’s wishes before the person becomes unconscious or too cognitively impaired to com- municate directly. Advance directives are documents that specify a patient’s wishes before hospitalisation and provide valuable information that may assist healthcare providers in

substances used to treat symptoms) and withholding a diagno- sis to the patient. Both involve the issue of trust, which is an essential element in a person-centred relationship. Placebos may be used in experimental research in which the patient is involved in the decision-making process and is aware that placebos are being used in the treatment regimen. However, the use of a placebo as a substitute for an active drug to show that the patient does not have real symptoms is deceptive. Informing patients of their diagnoses when the family and doctor have chosen to withhold information are ethical situations commonly encountered. Nurses often use evasive responses to the patient’s questions as a means of maintaining that request. This area challenges the nurse’s integrity as trust is an essential part of the therapeutic relationship. Strategies the nurse could consider in this situation include the following: • Being truthful to the patient. • Providing all information related to nursing procedures and diagnoses. • Communicating the patient’s requests for information to the family and doctor. Finally, although providing the information may be the morally appropriate choice, the manner in which the patient is told is important. Disclosure of information merely for the sake of patient autonomy does not convey respect for others. End-of-life issues Dilemmas that centre on death and dying are prevalent in medical-surgical nursing practice and frequently initiate moral discussion. The dilemmas are compounded by the fact that the idea of curing is paramount in healthcare. With advanced technology, it may be difficult to accept the fact that nothing more can be done, or that technology may prolong life but at the expense of comfort and quality of life. Focusing on the caring as well as the curing role may assist nurses in dealing with these difficult moral situations. End-of-life issues are dis- cussed in detail in Chapter 12. Pain control The use of opioids to alleviate a patient’s pain may present a dilemma for nurses. Patients with intractable pain may require large doses of analgesics. Fear of respiratory depression or unwarranted fear of addiction should not prevent nurses from attempting to alleviate pain for the dying patient or for a patient experiencing an acute pain episode. In the case of the terminally ill patient, for example, the actions may be justified by the principle of double effect (Chart 2-2). The intent or goal of nursing interventions is to alleviate pain and suffering while promoting comfort. The risk of respiratory depression is not the intent of the actions and should not be used as an excuse for withholding analgesia. However, the patient’s respir­atory status should be carefully monitored and any signs of respiratory depression reported to the doctor. Do-not-resuscitate orders Although it is acknowledged that there are various levels of a ‘do not resuscitate’ (DNR) order (also known as ‘not for resuscitation’ (NFR)) that can range from total DNR to ‘CPR but no intubation’, all these orders present controversial issues for nurses. When a patient is competent to make decisions, his or her choice for a DNR order should be honoured, according to the principles of autonomy or respect for the individ- ual (Johnstone, 2009). However, a DNR order is at times